A national study of psychiatry outpatient visits by lower-skilled male migrant workers in Qatar

Background Arab countries host 10% of all migrants globally. Migrant workers are known to have a high burden of physical and psychiatric morbidity. Most of the published literature on mental health among migrant workers is from non-Arab countries. The limited literature on migrant workers’ mental health in Arab countries is a critical research gap. It is pertinent to study well-defined migrant groups within well-defined host country conditions to yield pragmatic answers to inform service delivery. Aims The current study aims to complement existing data by characterizing psychiatric morbidity in a well-defined migrant group within a specifically defined context of migration. Methods Retrospective review of patient notes. Results All participants were men, and most of them were aged between 30 and 49 years. More than two-thirds presented with anxiety or depressive disorders. More than half had a past psychiatric history. Psychological distress was linked to stressors such as limited social support, living away from family, financial stressors, family-related stressors, and work-related stress. One-fourth of the participants reported stress related to the pandemic. Half of them reported physical health comorbidities. Two-thirds were not compliant with treatment plans, and one-fourth were lost to follow-up. Conclusion This is the first study to provide insight into the psychiatric morbidity of lower-skilled migrants presenting to outpatient psychiatry clinics in Qatar. The psychiatric morbidity of migrants is mainly centered around depressive and anxiety-related disorders. The most common challenges encountered in the management of patients include patient concordance with medication and loss to follow-up. Mitigation strategies are vital for ensuring the psychological well-being of migrant workers.


BACKGROUND
The International Labor Organization estimates that 164 million people are migrant workers; most are men (96 million), while 68 million are women.Nearly 61% of migrant workers are found in three subregions: 23.0% in North America, 23.9% in Europe, and 13.9% in Arab countries. 1The largest group of migrant workers in Arab countries are from South Asia (India, Pakistan, Bangladesh, Nepal, and Sri Lanka), Southeast Asia (the Philippines) and Africa (Egypt, Ethiopia, Kenya, and Uganda). 2 Male migrant workers outnumber female migrants due to the high demand and labor opportunities in the construction sector in Arab countries.Migrant workers are known to have a high burden of physical and psychiatric morbidity.4][5][6] Most of the published literature on mental health among migrants is from non-Arab countries.In a systematic review of migrant workers' psychological health, the studies included were mainly from the United States and China and reported a wide range of mental health issues, including anxiety, depression, alcohol or substance abuse, and poor sleep quality. 3The meta-analysis, involving 44,365 migrant workers in 17 different countries, reported an overall prevalence of depression and anxiety among migrant workers at 38.99% and 27.31%, respectively.Occupational factors, in addition to social factors, were found to be important determinants of mental health outcomes. 4This review included a total of 27 studies, with most studies being cross-sectional.][23][24][25][26][27][28] Along with a few of its immediate neighbors, Qatar is experiencing a rapid development phase of unprecedented growth funded by the region's oil and natural gas reserves.This situation, in fact, does lend itself to a more specific set of conditions that can yield data by looking at a specific group of migrants who share many of the determinants known to influence both reasons for migration and mental health.These conditions are Qatar's need for low-skilled laborers to build rapidly expanding infrastructure, a somewhat uniform background of the culture of South Asian countries that provides such labor, and uniform profiles of young men with limited skills who migrate without their families.The limited literature on migrant workers' mental health in Arab countries is a critical research gap.The current study was mainly descriptive and exploratory and aimed to complement existing data by characterizing psychiatric morbidity in a welldefined migrant group within a specifically defined context of migration using robust clinical data.It offers a broad clinical picture of the psychiatric problems presented to psychiatry clinics.These data should assist with service planning and future research.

Setting
This study was conducted at Hazm Mebaireek General Hospital (HMGH), a secondary healthcare facility run by the Hamad Medical Corporation (HMC).The HMGH is situated in the Doha Industrial Area (DIA), the capital of Qatar.The DIA is exclusively populated by lower-skilled migrant workers, with a total population of 4,25,000.Psychiatry outpatient services at HMGH, for lowerskilled male manual migrant workers, receive referrals from the Qatar Red Crescent Service, primary care services for lower-skilled migrants, the Emergency Department, inpatient units, and other outpatient services at HMGH and other hospitals associated with the HMC.Consultant psychiatrists completed all the psychiatric assessments.Patients are assessed face-to-face or virtually through a video or phone call.Psychiatrists at the HMGH are qualified Western multilingual psychiatrists who speak the same language as most patients; otherwise, translators are used.

Design, approval, and study population
The design was a retrospective review of electronic patient records taken in psychiatry outpatient clinics for lower-skilled migrant workers at HMGH.The study received approval from the HMC Institutional Review Board (IRB) (MRC-01-21-206).Individual patient consent was not deemed necessary by the IRB.While retrospective studies generally do not necessitate obtaining retrospective consent, securing consent for retrospective data can prove challenging, rendering it nearly unattainable.Hence, the IRB plays a pivotal role in assessing the necessity for consent.In our study, we pursued IRB approval, and the requirement for consent was waived, as the research was determined to entail minimal risk and would not adversely impact the rights and welfare of the subjects. 18egisters kept by the psychiatry team at HMGH were reviewed to identify the patients who met the following inclusion criteria: 1.Over the age of 18. 2. Patients who are COVID-19-negative.3. Lower-skilled manual migrant workers referred to psychiatry outpatient clinics at HMGH between July 2019 and December 2020.4. Patients who attended psychiatric outpatient clinics following a referral.

Data collection
The data collection procedure was designed to collect retrospective information from electronic medical records.Two research team members, KA and FK, extracted the data and held regular discussions to ensure consistency under the supervision of YI.The proforma collected demographic characteristics, physical comorbidity and medication details, past psychiatric history, and reasons for referral.The details of the psychiatric assessments performed by the consultant psychiatrists included the presence of psychiatric symptoms or signs, a history of substance misuse, VOL.2024 / ART.29 A national study of psychiatry outpatient visits by lower-skilled male migrant workers in Qatar a family history of mental illness, social stresses, a clinical diagnosis, a management plan, and any follow-up, as recorded in the notes.The diagnoses reflected clinical judgment by the psychiatrists and were not operationally defined.The data, including initial assessments and follow-up reviews, were extracted for the current outpatient journey.

Statistical analysis
We

RESULTS
Three hundred seventy-six (376) patients qualified to be part of this study over the designated study period.As expected, the population was somewhat homogenous, and most participants (73.1%, n = 275) were aged between 30 and 49 years.Most (77.4%, n = 291) were from the Indian subcontinent.The most common primary languages spoken were Hindi (56.6%, n = 213), English (13%, n = 49), and Arabic (10.6%, n = 40 A national study of psychiatry outpatient visits by lower-skilled male migrant workers in Qatar industry. 29The prevalence of various mental disorders in the published literature in Arab countries varies depending on the setting in which the study was conducted.In Kuwait, severe reactions to stress, manic episodes, depressive episodes, and acute and transient psychotic disorders are the most common disorders reported in an inpatient setting.Two-thirds of admitted housemaids presented with stress, anxiety, or depressive disorders.Psychiatric morbidity was 1.86 times greater in immigrant housemaids than in Kuwaiti female patients hospitalized during the 2-year study period. 30,31In the UAE, the prevalence of depressive symptoms among workers living in labor camps was 25.1%.Approximately 6% of participants in this cross-sectional study reported thoughts of suicide, and 2.5% had attempted suicide. 32In Saudi Arabia, the prevalence of depressive symptoms was found to be 20% in a community sample of low-income migrants. 33In Qatar, Khaled and Gray compared the prevalence of depressive symptoms among migrants and substandard working conditions characterized by meager wages, extended working hours, limited job security, and instances of workplace exploitation.The compounded effects of occupational hazards and adverse work environments exacerbate the vulnerability of migrant workers to adverse health outcomes, particularly concerning their mental well-being.More than two-thirds of the lower-skilled migrant workers in our study presented with anxiety or depressive disorders.It is well known that an increased frequency of anxiety and depression generally occurs in populations known to be under high stress, such as immigrants.A higher risk of anxiety and depression among migrant workers may be caused by elements like the experience of migration itself, exposure to stressors during the migration process, subpar living and working conditions, language barriers, restricted access to healthcare, and social isolation.A previous study indicated the difference in stressors experienced by migrant workers according to gender and working A national study of psychiatry outpatient visits by lower-skilled male migrant workers in Qatar adverse outcomes during the pandemic. 36,37All our participants were men, and most of them were aged between 30 and 49 years.This finding is consistent with the overall demographic data of lower-skilled migrant workers in Qatar, who constitute more than 50% of the population.Despite the younger age group of our sample, half of them reported physical health morbidity, and 84.6% reported social stress.This finding is consistent with the notion that social stresses and physical health morbidities are common in migrants and increase the risk of mental health problems. 38he findings indicate that pre-existing physical illness was linked to psychological morbidity in the study population.The odds of experiencing psychological distress are greater among migrants suffering from chronic diseases such as diabetes and hypertension than among those who are not. 39,40More than half of our sample had a past psychiatric history, mainly of anxiety and depressive disorders.The likelihood of an individual experiencing mental health issues is greater when they have a past psychiatric disorder.The most common challenges encountered in managing patients included patient concordance with medication and loss to follow-up.Two-thirds were not compliant with treatment plans, and onefourth were lost to follow-up.Migrant workers commonly experience financial limitations and a non-migrants and reported that the odds of depression significantly increased among labor migrants. 34In Lebanon, 66.7% of hospitalized female foreign domestic workers were diagnosed with brief psychotic episodes.Sexual, physical, and verbal abuse were reported by 12.5%, 37.5%, and 50.0% of workers, respectively. 35The psychiatric morbidity of migrants mostly centers around depressive and anxiety-related disorders rather than more severe and enduring mental disorders.We believe that there are several reasons for this.First, self-selection by individuals with a desire to migrate for economically productive reasons is followed by selection by companies recruiting individuals without serious mental illness.The psychological distress experienced by migrant workers leading to depressive and anxiety-related disorders is commonly linked to stressors such as an unpredictable work environment, job insecurity, living away from family and friends, language and geographical barriers, abuse, and exploitation.Similar factors, including limited social support, living away from family, financial stressors, familyrelated stressors, and work-related stress, were identified among the migrant workers in our study.
It is pertinent to note that, as our study was performed during the COVID-19 pandemic, onefourth of the participants reported stress related to the pandemic.Migrants were at increased risk of

CONFLICT OF INTEREST STATEMENT
All authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.

AUTHORS' CONTRIBUTIONS
JL, OW, YI, and MA conceived the idea for the research.KA and FK collected the data under the supervision of YI.SO, SR, and OW analyzed the lack of insurance coverage, which constrains health-seeking behavior among migrant workers. 41,42

STRENGTHS AND LIMITATIONS
This study is a first step toward highlighting the mental health needs of lower-skilled male migrant workers and will help to organize services and interventions in accordance with the type and severity of mental disorders in this patient group.
Our approach was mainly descriptive and exploratory; nonetheless, the findings might be generalizable to other neighboring Arab countries with similar demographic and sociocultural contexts.The main limitation is that this was a retrospective case-note review, and the data captured were dependent on the quality of the medical records.The retrospective examination of medical records is a valuable methodological approach in clinical research; however, it is accompanied by inherent limitations.These encompass deficiencies in documentation completeness, encompassing instances of absent charts and unrecoverable or unrecorded data.Furthermore, challenges arise in the interpretation of information within the documents, hindered verification of data accuracy, and the establishment of causal relationships.Additionally, variability in the quality of information recorded by healthcare professionals poses a significant concern. 43No data are available for lower-skilled female migrants, as psychiatry clinics at HMGH only receive referrals for male patients.Future research should employ prospective epidemiological designs and incorporate standardized diagnostic assessments.The efforts to include diverse migrant populations, including women and higher-skilled workers, would contribute to a more comprehensive understanding of mental health issues in migrant communities.

CONCLUSION
This is the first study to provide insight into the psychiatric morbidity of lower-skilled male migrants presenting to outpatient psychiatry clinics in Qatar and other Arab countries.These findings are used Microsoft Excel 2019 for Windows to enter the data.Microsoft Excel 2019 for Windows and SPSS version 26 for Windows were used to analyze the data.We determined the absolute and relative frequencies (percentages) for each studied categorical variable.

Table 1 . Sociodemographic and clinical features of the participants.
). Almost half (48.6%, n = 154) had physical comorbidities, and 14.2% (n = 40) had a positive family history.The sociodemographic and clinical features of the participants are detailed in Table1.n= 118), and depression (17.8%, n = 67).The results of our research indicate that migrants are more likely to suffer from anxiety and depression.Fifty-nine (59, 15.7%) did not attend the first 7%, n = 72), living away from family (22.4%,n= 71), financial stressors (15.1%, n = 48), familyrelated stressors (12.0%, n = 38), and work-related stress (11.0%, n = 35).To our knowledge, this is the most comprehensive review of the mental health symptoms and diagnoses of lower-skilled migrants presenting to psychiatry outpatient clinics in an Arab country.It is VOL.2024 / ART.29